Consent for Dental Extractions
I, , hereby consent to the following teeth to be extracted by Brent Call D.M.D., a
My dentist has determined that my teeth are non-restorable and need to be removed, or that my teeth are
restorable but as an alternative to restoration of my teeth I have chosen to have them removed. In the case of fully
impacted and partially impacted wisdom teeth (3rd molars), the reason for extraction has been explained, and I
understand the expected benefits of extraction. Although wisdom teeth (3rd molars) do not always require removal, I
have chosen to have them removed at this time.
The oral surgical procedures to be performed have been explained to me and I am satisfied that I understand
what is to be done. I agree to the use of local anesthetic and antibiotics as deemed necessary by Brent Call D.M.D.
I understand that there are risks of complications associated with surgery, drugs and local anesthesia. The more
common complications are post-operative pain, infection, swelling, bleeding, bruising/discoloration, and temporary
or permanent parasthesia (tingling) or anesthesia (numbness) of the lip, tongue, chin, gums, cheek, or teeth
(especially associated with the lower jaw). I am aware that injury to or stiffness of the neck and facial muscles,
changes in tempormandibular joint and occlusion of teeth may occur. I am aware that injury to other tissues, adjacent
teeth, restorations in other teeth, referred pain to the ear, head neck, nausea, vomiting, allergic reactions, bone
fractures, and delayed healing are all possible during or after dental extractions.
I understand that removal of upper teeth may result in sinus complications, including an opening into the sinus
from the mouth. I also understand that some fractured root tips cannot be recovered with traditional extraction
methods. In both situations, surgical intervention by an oral surgeon may be required.
I am aware that pain medication may cause drowsiness and lack of awareness or coordination, which could
increase by the use of alcohol or other drugs. I will not
- operate any vehicle
- operate any hazardous devices
- be responsible for children while taking such medications for at least 24 hours or until fully recovered from
the effects of the medications given me.
I have been advised of other treatment modalities for the present oral condition and choose to have oral
surgery/dental extractions over all other options.
I have been informed of the option of having a bone graft done in conjunction with dental extractions to aid in
healing and preservation of bone in the mouth. The risks and benefits of bone grafts have been explained to me. If I
choose to have a bone graft performed, I am aware that human cadaver bone is usually used for the bone graft and I
consent to its use.
I acknowledge the receipt and understand the post operative instructions. I understand that complications with
healing are common in oral surgery/ dental extractions and that follow-up care is available to me.
The fee for my treatment has been explained to me and is satisfactory. I am aware that occasionally further
treatment due to complications may be required and that there are reasonable fees associated with these treatments.
I freely give consent for Brent Call D.M.D to perform dental extractions on me.
Signature of Patient or Guardian
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